[Application of guidelines in clinical practice: a multicenter analysis of the treatment of membranous glomerulonephritis in Piedmont, Italy].

The treatment of membranous glomerulonephritis (MGN) is controversial, especially in cases of no response to first-line treatment or multiple relapses. The Clinical NephrologyGroup of Piedmont carried out a multicenter analysis of the treatment of patients affected by MGN in 15 nephrologyunits in Piedmont. The first treatment is usually started after a waiting period of 3-6 months in case of proteinuria in the nephrotic range but normal or slightly impaired renal function. A history of cancer, the presence of infectious disease, and secondary forms of MGN are criteria for exclusion from treatment. As first-line treatment, Piedmont nephrologists prescribe corticosteroids alternated with immunosuppressive drugs, generally preferring cyclophosphamide to chlorambucil. Only one nephrologyunit uses cyclosporin A (CyA) as the first choice. In case of no response to treatment, a second therapeutic approachis undertaken after 2-12 months. Second-line treatment consists of CyA if immunosuppressive drugswere given before, and corticosteroids/ immunosuppressive drugsif CyA was the first treatment. A further choice may be ACTH or rituximab. In case of multiple relapses the treatment options are the same but previous immunosuppressivetreatment, patient age, and the duration of kidney disease with a greater probability of renal failure and progression towards sclerosis require careful attention. Concern has been expressed regarding the potentially severe side effects of ACTH including myopathy, cataract and diabetes. In conclusion, the applied therapeutic approachesin Piedmont reflect the difficulty reported in the literature in identifying simple recommendations. ACTH and rituximabare increasingly preferred for the treatment of MGN and there is a need for prospective studies to determine the best protocol for rituximaband the safety profile of ACTH.